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中华移植杂志(电子版) ›› 2023, Vol. 17 ›› Issue (06) : 372 -380. doi: 10.3877/cma.j.issn.1674-3903.2023.06.009

综述

门静脉血栓分型与肝移植门静脉重建策略探讨
罗星玉1, 杨喆2, 郑树森2,†()   
  1. 1. 310053　杭州，浙江中医药大学研究生院；310015　杭州，浙江树人大学树兰国际医学院附属树兰（杭州）医院肝胆胰外科
    2. 310015　杭州，浙江树人大学树兰国际医学院附属树兰（杭州）医院肝胆胰外科
  • 收稿日期:2023-06-19 出版日期:2023-12-25
  • 通信作者: 郑树森
  • 基金资助:
    国家自然科学基金重大研究计划项目(92159202); 浙江省重点研发计划项目(2023C03046); 浙江省自然科学基金(Y21H160259); 海南省重大科技计划(ZDKJ2019009); 济南微生态生物医学省实验室科研项目(JNL-2022016B); 中央高校基本科研业务费专项资金资助项目(2022ZFJH003)

Exploring the classification of portal vein thrombosis and portal vein reconstruction strategies in liver transplantation

Xingyu Luo1, Zhe Yang2, Shusen Zheng2,†()   

  1. 1. Graduate School, Zhejiang Chinese Medical University, Hangzhou 310053, China; Department of Hepatobiliary and Pancreatic Surgery, Shulan (Hangzhou) Hospital Affiliated to Zhejiang Shuren University Shulan International Medical College, Hangzhou 310015, China
    2. Department of Hepatobiliary and Pancreatic Surgery, Shulan (Hangzhou) Hospital Affiliated to Zhejiang Shuren University Shulan International Medical College, Hangzhou 310015, China
  • Received:2023-06-19 Published:2023-12-25
  • Corresponding author: Shusen Zheng
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罗星玉, 杨喆, 郑树森. 门静脉血栓分型与肝移植门静脉重建策略探讨[J]. 中华移植杂志(电子版), 2023, 17(06): 372-380.

Xingyu Luo, Zhe Yang, Shusen Zheng. Exploring the classification of portal vein thrombosis and portal vein reconstruction strategies in liver transplantation[J]. Chinese Journal of Transplantation(Electronic Edition), 2023, 17(06): 372-380.

非肿瘤性门静脉血栓形成(PVT)是晚期肝硬化等待肝移植患者的严重并发症之一，且会影响移植后结局。目前虽已有众多学者提出多种PVT分级方法，但许多分级方法对于如何利用门体侧支循环进行吻合却没有详细定论，这使得PVT的治疗和肝移植术中门静脉重建更加困难和复杂。充足的门静脉血流是保证肝移植术后受者及移植物存活的重要因素。对于非复杂性Yerdel 1～3级PVT患者可术中行门静脉血栓切除术及解剖吻合达到生理性重建；而对于复杂性Yerdel 4级PVT，可能须利用内脏曲张静脉、肾静脉进行门静脉血流重建，有时甚至须行腔门静脉吻合、门静脉动脉化或多脏器联合移植。本文综述国内外最新PVT分型、生理与非生理性门静脉重建的定义、术中门静脉吻合方式及PVT围术期管理，以期为临床上制订合理的门静脉重建方案提供参考。

关键词: 肝移植, 门静脉血栓形成, 门静脉重建, 围手术期管理

Non-tumoral portal vein thrombosis (PVT) is a significant complication in patients with advanced cirrhosis waiting for liver transplantation, and can impact post-transplant outcomes. Although many scholars have proposed various PVT classification methods, many classifications have no detailed conclusion on how to use the portosystemic collateral circulation for anastomosis, which makes the treatment of PVT and portal vein reconstruction during liver transplantation more difficult and complex. Adequate portal vein flow plays a crucial role in ensuring the recipient′s and graft′s survival after liver transplantation. Intraoperative portal vein thrombectomy and anatomic anastomosis can achieve physiologic reconstruction in patients with uncomplicated Yerdel grade 1-3 PVT, while for complex Yerdel grade 4 PVT may need portal vein revascularization using visceral varicose veins, renal vein, and sometimes even cavoportal anastomosis, portal vein arterialization, or combined with multiple organs transplantation. Therefore, this article aims to review the latest domestic and international staging of PVT, definition of physiological and non-physiological portal vein reconstruction, intraoperative portal vein anastomosis modalities, and perioperative management of PVT, hoping to provide a clinical reference for portal vein reconstruction protocols.

Key words: Liver transplantation, Portal vein thrombosis, Reconstruction of portal vein, Perioperative management
表1 PVT分级(无侧支循环或门体分流)
文献 1级 2级 3级 4级
Stieber等[29] PV主干(节段性)血栓形成(部分或完全) 血栓扩展至SMV(部分或全部) 血栓形成延伸至SV(部分或完全) 弥漫性，累及SMV和SV(完全)
Nonami等[30] 肝内PV分支血栓形成 PV右分支或左分支或分叉处血栓形成 PV主干部分梗阻 PV主干完全梗阻
Gayowski等[31] PV主干部分PVT延伸至汇合处或汇合处以下 PV主干完全PVT，未延伸至SMV和SV PV主干完全PVT，延伸至SMV和SV汇合处水平 PV主干完全PVT，并延伸至汇合处以下
Yerdel等[32] PV闭塞程度<50%，伴或不伴轻度SMV血栓 PV闭塞程度>50%，伴或不伴轻度SMV血栓 PV及近端SMV完全血栓，远端通畅 PV、近端及远端SMV完全血栓
Bauer等[33] PV闭塞程度≤25% PV闭塞程度26%～50% PV闭塞程度51%～75% PV闭塞程度≥76%
Ma等[34] 部分性PVT不伴海绵状血管瘤 部分性PVT伴海绵状血管瘤 完全性PVT不伴海绵状血管瘤 完全性PVT伴海绵状血管瘤
Sarin等[35] PVT累及1个(2a型)或2个(2b型)肝内PV分支(部分或完全) PVT局限于PV主干(部分或完全) PV主干和分支PVT(部分或完全) PVT位于PV主干和分支，并累及SMV±SV(部分或完全)
Teng等[36] 位于PV分支和主干的PVT，可行门静脉常规端端吻合重建 移植肝门静脉重建后血流来自受者门静脉系统 移植肝门静脉重建后血流来自受者非门静脉系统 －
表2 PVT分级(含侧支循环或门体分流)
文献 1级 2级 3级 4级
Bhangui等[6] Yerdel 1～3级 复杂PVT(Yerdel 4级、Jamieson 3～4级和Charco分级的3～4级)，存在自发性或手术分流 复杂PVT(Yerdel 4级，Jamieson 3～4级和Charco分级的3～4级)不存在自发性或手术分流 －
Jaimeson等[37] PVT局限于PV与SMV汇合处以上，无论阻塞程度 PVT延伸至近端SMV，但SMV通畅 弥漫PVT伴粗大侧支循环形成 弥漫PVT伴纤细侧支循环形成
Charco等[38] 局限于PV主干的PVT(部分或完全) PVT延伸到SMV近端部分，且累及SV与SMV汇合处 弥漫血栓伴侧支循环形成 弥漫血栓不伴侧支循环形成
Kim等[39] PVT位于SMV与PV汇合处之上 PVT延伸至SMV与PV汇合处之下，远端SMV通畅 PVT延伸至远端SMV，伴冠状静脉侧支形成 PV主干、SMV和SV完全PVT，冠状静脉血栓形成
Yang等[40] PVT位于PV与SMV汇合处以上，侧支循环不明显 PVT位于PV与SMV汇合处上方，并伴有明显侧支循环 PVT延伸至PV与SMV汇合处以下，但SMV近端通畅 PVT延伸至SMV(完全)，伴有通畅的自发性或手术分流
表3 PVT患者不同门静脉血流重建方式对受者和移植肝生存率影响情况
文献 术式(例) 男性[例(%)] 中位年龄[岁，M(P25，P75)] 中位随访时间[月，M(P25，P75)] 血栓分级(Yerdel) 术后受者生存率(%) 术后移植物生存率(%)
1～3级[例(%)] 4级[例(%)] 1年 3年 5年 1年 3年 5年
Pinelli等[4] TAA(79) 64(81) 58(48，68) 48(18，78) 79(100) 0 82 78 71 79 74 68
  非TAA(18) 12(67) 52(46，58) 48(12，84) 17(95) 1(5) 61 56 56 61 56 56
Fundora等[7] RPA(74) 55(74) 59(52，64) 22( 4，67) 0 74(100) 74 72 63 74 68 60
  LGA(18) 14(78) 59(47，61) 22( 4，67) 0 18(100) 70 70 70 64 64 64
  PCA(20) 17(85) 56(52，61) 22( 4，67) 0 20(100) 85 79 79 78 72 72
  CPA(22) 19(68) 55(43，65) 22( 4，67) 0 22(100) 52 42 33 52 42 33
Azoulay等[50] RPA(57) 44(77) 58(47，63) 63( 2，11) 4(7) 53(93) 87 83 76 82 80 73
Vianna等[51] 多器官联合移植(25) 19(76) 53.0(2.5，67.0) 33.6(20.4，56.4) 0 25(100) 80 72 72 80 72 72
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